Nursing Shortage: Not a Simple Problem - No Easy Answers

Abstract

The article examines the issue of nursing workforce planning within the present health system environment and addresses ethical issues related to the shortage. Numerous factors are influencing both the supply of registered nurses as well as the demand for nursing services. Of particular concern is the negative impact that the current nursing practice environment is having on the retention of registered nurses as well as the ability of the profession to recruit students. Other factors driving this present nursing shortage include the increasing age of working nurses and the potential for retirement; the aging of nursing faculty impacting the capacity of nursing schools; and poor wage compensation. The continual swing in the supply of and demand for nursing services will always be present; however, it is time that nursing sat at the policy-making table with the other decision makers to better anticipate the nature of these changes and how to address them.

The question frequently asked of nursing today is, "Is there a nursing shortage in the U.S.?" Unfortunately, a simple "yes" or "no" response to this question is not possible. At 2.5 million registered nurses, 82.5 percent of whom are employed in nursing, we are the largest number of health care professionals in the United States. The dynamics impacting the supply, demand and need for registered nursing services, particularly in this present climate, are often unpredictable and dependent on forces, such as Medicare and Medicaid reimbursement, that are presently beyond nursing's control. Complicating this discussion is the variation in health delivery systems and culture at regional and local levels. This article briefly discusses what we know about the nursing shortage, some of the ethical implications, and the factors that are presently influencing the overall supply of registered nurses.

The rapid changes in the financing and organization of health care delivery through the 1990's continue today. Multiple interrelated factors affecting the demand for nursing services have been identified by researchers and professional organizations. These factors include:

A shift of outpatient care from hospitals to ambulatory and community-based settings

To some degree or another, many of these same factors continue to influence the U.S. health care delivery system today.

Geolot (2000) predicts that in 2010 the projected full-time equivalent supply of registered nurses will no longer exceed requirements for full-time equivalent registered nurses. This is the predicted intersection to a shortage. The years following 2010 show a dramatic widening between the supply of registered nurses in relation to the requirements for registered nurses.

Some states are already reporting difficulty in hiring experienced and specialty nurses and recruiting time is beginning to lengthen. This is in spite of an increase in the overall supply of registered nurses. According to the 1996 National Sample Survey of Registered Nurses (Moses, 1997), the total number of employed registered nurses increased at an average annual rate of 3.4 percent between 1992 and 1996 with 82.7 percent of the registered nurse population employed in nursing. During this same time frame, the number of registered nurses employed full-time increased from 57 percent (1992) to 59 percent (1996).

It is clear that in the near future there will be a problem with the supply of registered nurses as a result of declining enrollments in nursing programs and aging of the nursing workforce. The other parts of this equation, demand (an economic term defining what the industry will bear) and need (a health-related term) are more difficult to measure. The dynamics impacting the demand for registered nursing services are primarily economic in nature: how much reimbursement will the facility receive for the care provided and how many workers and at what cost are employers willing to hire.

The need for registered nursing services, i.e., the health of a community or the aging of the population, as articulated by Prescott (2000), is often a secondary consideration for those who hire registered nurses and thus drive the demand. According to Prescott, the need for registered nurses usually exceeds the demand or the number of registered nurses that health care systems are willing to employ.

In an effort to look at this problem from a different perspective, this article examines the issue of nursing workforce planning within the present health system environment. It is relatively easy to look at the supply of nurses from a sterile viewpoint of enrollments, potential retirements, and an aging workforce. However, this fails to capture the fundamental problem that nurses face today - the environment of care. On the heels of almost a decade of constant health system change, reorganization, re-engineering, and changes in reimbursement and funding mechanisms, the overall environment of care has deteriorated to such an extent that many registered nurses have difficulty encouraging others to even enter the nursing profession. It is this problem that will be the most difficult to address unless everyone is engaged in this discussion. Registered nurses, hospital administration, other health care providers, health system planners, and consumers must come together in a meaningful way to create a health care system that supports quality patient care and all health care providers.

The reality is that the profession of nursing will be unable to compete with the myriad of other career opportunities unless we improve working conditions, increase compensations over the lifetime of the registered nurse and provide clinical practice opportunities and responsibilities that match the registered nurse's knowledge and skill.

The reality is that the profession of nursing will be unable to compete with the myriad of other career opportunities unless we improve working conditions, increase compensations over the lifetime of the registered nurse and provide clinical practice opportunities and responsibilities that match the registered nurse's knowledge and skill.

Ethical Dimensions of Nurse Staffing

Element nine of the Code for Nurses (American Nurses Association1985) states that "the nurse participates in the profession's efforts to establish and maintain conditions of employment conducive to high quality nursing care." The interpretive statements further add the "responsibility for conditions of employment" and "maintaining conditions for high quality nursing care." As professionals, registered nurses are truly caught between the strong desire to adhere to the Code for Nurses while struggling to impact an ever-changing health system where others' motivations may be different. Numerous registered nurses have shared with this author their feelings that their ability to advocate for their patients, their professional integrity and personal nursing practice, and their physical well-being have been jeopardized by changes in the health system that have gone unevaluated and without oversight by regulatory agencies.

The American College of Healthcare Executives (Darr, 1991) has a Code of Ethics. The Preamble states that "Since every management decision affects the health and well-being of both individuals and communities, healthcare executives must evaluate the possible outcomes of their decisions and accept full responsibility for the consequences." Issues related to creating a workplace that supports excellence in patient care and facilitates career progression is the responsibility of the American Nurses Association(ANA) and state nurses associations, nurse educators, registered nurses, management and administration. Of particular concern, is the loss of visible nursing leadership in nursing administration and diminished access to clinical nurse expertise such as Clinical Nurse Specialists and other advanced practice nurses. Both of these components were early casualties of the wave of restructuring that swept through during the 1990s and must now be rebuilt.

Factors Influencing the Supply of Registered Nurses

Work Environment

One of the most significant factors that contribute to the difficulty in both recruiting and retaining registered nurses is the care environment.

One of the most significant factors that contribute to the difficulty in both recruiting and retaining registered nurses is the care environment.

While pay rates continue to be a problem, the care environment is a primary motivator for individual registered nurse's making employment choices. Studies (Healthcare Information Resource Center, 1998; William M. Mercer, Inc., 1999) have shown that one of the primary factors for the increasing nurse turnover rate is workload/staffing. According to the Healthcare Information Resource Center (1998) nursing shortage study (Hay Group Study), nursing managers, registered nurses and licensed practical nurses all cited "insufficient supply of qualified managers/experienced staff" as the most likely reason for the current or anticipated shortage. In contrast, the William M. Mercer (1999) study showed that the primary reason for nurse turnover was "increased market demand." Mercer goes on to state that in their work they have found that the "underlying cause of turnover is dissatisfaction with the job, the supervisor, or career prospects." The second most cited reason for turnover was "workload/staffing." These are fundamental problems that stand separate from the issues related to the supply of and demand for nursing services. Unless issues related to the care environment are addressed, strategies to increase the overall supply of nurses are unlikely to be successful.

Recruitment

Numerous efforts are presently underway to recruit more students into nursing. It is clear that the profession is competing against many other career opportunities. The National Student Nurses' Association has produced a video, Nursing: The Ultimate Adventure, targeted at junior and senior high school students. In addition, American Nurses Association has joined with Sigma Theta Tau and 16 other nursing and health organizations, in the development of a media campaign designed to recruit new nurses and encourage existing ones to remain in the profession.

Along with the need to recruit into the profession, nursing must continue to examine the ways in which new nurses are introduced into the nursing work culture. Adequate orientation, mentoring, and preceptor programs are absolutely essential to both introducing and retaining new nurses. Many facilities eliminated these programs for reasons associated with cost during reorganization efforts. This has proven to be very short-sighted as facilities are now working to rebuild these programs.

One of the ongoing problems within nursing is the ability to maintain an adequate supply of specialty nurses. As facilities reestablish preceptor programs, consideration must be given to how these programs can serve a nurse throughout an entire career and provide the guidance needed to move into specialty areas. Career progression has been identified as one of the "qualities" of a workplace that is valued by registered nurses.

Retention

Concerns about the aging of the nursing workforce have been well documented. The present average age of registered nurses is 44.3 years with registered nurses who are under 30 years of age representing only 10 percent of the total nurse population (Moses, 1997). According to The Conference Board (SAIF, 1995), an employment and market analysis firm, chronological age is a poor indicator of physical or mental ability; turnover rates of older workers are lower than those of young employees; older workers learn as well as younger ones, except when stress is applied; and updating skills of existing employees will be a third as expensive as hiring new graduates schooled in the latest technologies. In addition, given the time needed to increase the supply of registered nurses through education, nursing and the health care industry must develop strategies that will retain the older, expert registered nurse within the nursing workforce.

A review of the literature shows that very little research has been done, particularly within nursing, about the impact of the aging workforce and potential accommodations that may need to be made in order to retain the experienced nurse.

A review of the literature shows that very little research has been done, particularly within nursing, about the impact of the aging workforce and potential accommodations that may need to be made in order to retain the experienced nurse.

Minnick, Fellow of the American Academy of Nursing, in a presentation entitled The RN Workforce in 2005: Retirement and the Baby Boomers spoke to the need for additional research and policy discussions related to pension availability, adult dependent care responsibility, and the perceived desirable working conditions of persons >55 years of age. Minnick went on to say that "given the enormous change boomers brought to the nursing labor market in the 1970s by their persistent labor participation, it is not inconceivable that this group may forge new patterns at the end of their careers."

An interactive study (Keddy, 1994) identified issues related to menopause that, while not disabling, may need to be accommodated. Some nurses interviewed for this study also expressed concern about job security if such issues were raised. In Belgium (Williams, 2000), one strategy that was secured through strike action to retain the expert, older nurse is to shorten hours of work. Nurses who are over 45 can work 36 hours a week, but still get paid for 38 hours (a standard work week). Similarly, nurses at 55 can work 32 hours a week and get paid for 38 hours.

Education

Historically, nursing has sought to educate its way out of a nursing shortfall. Presently, one of the most critical problems facing nursing and nursing workforce planning is the aging of nursing faculty. According to an American Association of Colleges of Nursing's (AACN) 1998 Issue Bulletin, nursing school associate professors and assistant professors are an average age of 52.1 and 48.5 years. This problem is even more acute at the doctoral level where, in 1996, the average age of new doctoral recipients was 45 years. Both the aging of nursing faculty and overall flat enrollment in doctoral programs that produce nurse educators will impact the capacity of nursing schools to educate sufficient numbers of registered nurses to meet the future demand.

Finally, a concerted effort must be made to ensure that the undergraduate nursing curriculum truly prepares the new graduate for today's environment.

Finally, a concerted effort must be made to ensure that the undergraduate nursing curriculum truly prepares the new graduate for today's environment.

A realistic understanding of the care environment and the appropriate critical and ethical knowledge and decision-making skills are essential to the survival of a new graduate.

Compensation

As noted in the work of Buerhaus (1998), during the 1980's, registered nursing hourly wages increased by approximately 3 percent each year. Through the 1990's, growth in the registered nursing wages was flat. However, the 1999 RN Salary Survey (Ventura) did show that hourly wages are again increasing. On average, full-time acute care registered nurses' straight hourly pay increased by 51/2 percent since the 1997 survey. This wage increase is not reflected in salaried nurses, who are primarily those who work in management and administration. The survey shows a 17 percent drop for salaried nurses since 1997.

A review of negotiated nursing contracts by the author shows that year-to-date on average unionized nurses are negotiating 3 percent to 5 percent wage increases in 2000. However, significant gains have been made in many contracts to address issues such as mandatory overtime and staffing, both issues that are directly impacting nurse satisfaction with the care environment.

Wage increases are, however, very much a reality for hospital executives and CEOs. According to the Hay Group's 10th Annual Compensation & Salary Guide (Bolster & Hawthorne, 2000), the base median CEO salary is up to $216,600 a year, compared with $180,000 a year in 1999; the total median compensation is up to $230,000; total compensation for incumbent CEOs rose 7.8 percent this year. The report notes that while cash compensation for a CEO position increased by 6.8 percent in 2000 and other executives got a 5.1 percent pay hike, nurses were getting a mere 3.2 percent increase.

Recruitment of Foreign Nurses

The International Council of Nurses' (ICN) 1999 position statement Nurse Retention, Transfer and Migration recognizes the right of individual nurses to migrate, while acknowledging the possible adverse effect that international migration may have on health care quality. However, the statement also condemns the practice of recruiting nurses to countries where authorities have failed to address human resource planning and problems, which cause nurses to leave the profession and discourage them from returning. The ANA (Congress on Nursing Practice & Economics, 2000) believes that the U.S. health care industry has failed to maintain a work environment that is conducive to safe, quality nursing practice and that retains experienced U.S. nurses within patient care. The Congress on Nursing Practice & Economics (2000) reports that the practice of changing immigration law to facilitate the use of foreign educated nurses is a short term solution that serves only the interests of the hospital industry, not the interests of patients, domestic nurses or foreign-educated nurses.

Conclusion

In order to for nursing to survive and thrive, the cyclical swings of the nursing shortage must be addressed. While solutions to this problem will be discussed more fully in other articles, the author would offer the following thoughts. As already stated, failure to address the work environment will make any strategies to address overall nursing workforce planning and the nursing shortage very difficult.

It is time for a concerted effort to move nursing workforce planning to the state level through the creation of state-based nursing workforce centers that could track, analyze and make recommendations on the nursing workforce within the state

It is time for a concerted effort to move nursing workforce planning to the state level through the creation of state-based nursing workforce centers that could track, analyze and make recommendations on the nursing workforce within the state. Each of these centers could collect comparable data that could inform nursing workforce planning at the national level to address this issue from a macro level. In addition, increased nursing education dollars are needed to increase the capacity of our schools of nursing. Finally, current work that is underway to link nursing care with patient outcomes is absolutely essential for determining the demand for nursing services from a patient perspective. As a complement to this information, organized nursing must demand that the Health Care Financing Administration develop mechanisms for costing out registered nurse services within Medicare, Medicaid and other reimbursement systems. By understanding both the demand for nursing services from the patient perspective and recognizing the cost implications, nursing can carry out more appropriate and timely workforce planning.

The Code for Nurses (ANA, 1985) governs all registered nurses, whether an educator, regulator, administrator, researcher or direct care provider, and serves as a mandate for action. Now is the time to create an environment that serves the interests of our patients, protects the public safety and ensures the ongoing viability of nursing. Flexibility in the workplace, a seat at the policy and planning table, opportunities for career progression, appropriate compensation, and recognition for work are the elements of a workplace and a profession that, if addressed, will promote growth by retaining the expert professional and attracting a new cadre of workers who are interested in a premier profession. The situation is such that failure to act will lead to further erosion of the care environment and the profession.

Cheryl A. Peterson, MSN, RN, is a Senior Policy Fellow, Health & Economic Policy at the American Nurses Association. Through her work at ANA, Ms. Peterson has studied the issue of workforce planning and trends related to the supply of and demand for nursing services. Ms. Peterson has a Baccalaureate in Nursing from the University of Cincinnati and a Masters in Nursing Administration from Georgetown University.

SAIF (State Accident Insurance Fund) Corporation (1995, May). The graying of the baby-boomers: facing up to an aging workforce. Retrieved November 12, 1999, from the World Wide Web: www.saif.com/safety_artc/aging.htm